Failure to Implement and Document Pressure Ulcer Prevention and Care Interventions
Penalty
Summary
The facility failed to implement and document appropriate pressure ulcer prevention and care interventions for multiple residents at risk for or with existing pressure ulcers. For one resident with a history of stroke, hemiplegia, diabetes, and reduced mobility, the facility did not comprehensively assess a right heel pressure ulcer. Weekly wound assessments repeatedly omitted depth measurements for a Stage III ulcer, and the last two assessments did not include staging. The wound nurse, who was not wound certified, acknowledged these omissions and inconsistencies in the wound documentation, despite the presence of a care plan and physician orders for wound care. Another resident, who was dependent on staff for bed mobility and transfers and identified as at risk for pressure ulcers, did not have prescribed heel offloading interventions implemented. Observations over several days showed the resident's heels in direct contact with the mattress, with no pillows or offloading devices in use, despite care plan instructions to encourage or assist with heel offloading. Interviews with CNAs and LPNs confirmed that the intervention was not being carried out, and staff were unaware of the care plan requirements or had not attempted to implement them. A third resident, identified as high risk for pressure ulcers due to multiple comorbidities and reduced mobility, did not consistently receive pressure-relieving devices as specified in the care plan. The resident and family reported inconsistent use of heel offloading pillows and absence of a pressure-relieving cushion in the recliner, where the resident spent most of his time. Observations confirmed the lack of required devices in the resident's room and chair, and staff interviews revealed uncertainty about the location and use of these devices. The facility's policy required identification of at-risk residents and implementation of interventions such as floating heels and use of pressure-relieving devices, but these were not consistently followed.